Program Operations Manual System (POMS)

HI 00601.620 District Office Role

When any provider in the DO’s service area has been authorized to make charges for excess costs, the DO must be alert to the possibility of complaints from beneficiaries regarding these charges for covered services. Notice having been given to the public and to the beneficiary concerning the provider’s right to charge (see HI 00601.600), the DO should be able to explain the basis for the charges. To assist the DO, the CMS RO issues lists of providers authorized to make specified charges and updates these lists periodically.

A beneficiary who believes that a high-cost provider’s charge for services is unwarranted because the services constitute emergency services files his protest with the provider. If the beneficiary telephones his protest to the DO, he should be referred to the provider. If he makes his protest in person, obtain his statement on an SSA-795, explaining why he thinks the services were emergency services. Forward a copy of the SSA-795 to the hospital for necessary action, and send the original to the CMS RO as a control.

Unless the hospital concedes that the services in question were furnished in the most accessible hospital, the CMS RO may call upon the DO to complete an HCFA-1771A by contact with the hospital. The references to “participating hospital” and “nonparticipating hospital” should be changed to “hospital which makes no charges for excess cost” and “hospital which charges for excess cost” respectively.

Where a beneficiary complains that an excess cost provider is charging more than the allowable excess costs, there is no appeal available. However, forward any such complaint to the CMS RO to resolve the issue. It will find either that the beneficiary is mistaken and provide him with an explanation; or, if the provider is wrong, assure that it rectifies its actions.